Attachment III: Life Agent Disclosure
Requirement (AB2107, Chapter 547) (Continued)
Life Agent Financial Products Disclosure (Continued)
PERSONAL PROPERTY & OTHER EXEMPT ASSETS
IRAs, KEOGHs, & Other Work-Related Pension Plans: These funds are exempt if the family member whose name it is in does not want Medi-Cal. If held in the name of a person who wants Medi-Cal and payments of principal and interest are being received, the balance is considered unavailable and is not counted. It is not necessary to annuitize, convert to an annuity, or otherwise change the form of the assets in order for them to be unavailable.
PERSONAL PROPERTY USED IN A TRADE OR BUSINESS
ONE MOTOR VEHICLE
IRREVOCABLE BURIAL TRUSTS OR IRREVOCABLE PREPAID BURIAL CONTRACTS
THERE MAY BE OTHER ASSETS THAT MAY BE EXEMPT.
This is only a brief description of the Medi-Cal eligibility rules, for more
detailed information, you should call your county welfare department. Also, you
are advised to contact a legal services program for seniors or an attorney that is
not connected with the sale of this product.
I have read the above notice and have received a copy.
Date:_______________________________________
Signature:___________________________________
Signature:___________________________________
The statement required in this subdivision shall be printed in at least 12-point type, shall be clearly separate from any other document or writing, and shall be signed by the prospective purchaser and that person's spouse, and legal representative, if any.
The State Department of Health Services (www.dhs.ca.gov/mcs/default.htm) shall update
this form to ensure consistency with state and federal law and make the disclosure available to advisers and brokers through its Internet Web site.
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